Soaking in Midwiferyby Andrea Boltz

[Editor's note: This article first appeared in Midwifery Today Issue 81, Spring 2007.]
This is an address given at the Midwifery Today International Conference, Bad Wildbad, Germany, October 2006.

When I learned about the topic of the opening session of the October 6, 2006, Midwifery Today conference in Bad Wildbad, Germany—Renewing the Soul of Midwifery with Visions and Dreams—I felt like sitting back and taking a deep breath. Visions and dreams are not what springs to mind first when we think of the present-day situation of midwifery in Germany and no doubt in most of your home countries as well. Let me give you a few examples of the situations midwives face in Germany these days:

Industrialized Birth Procedures

Many hospitals have highly-industrialized birth procedures, with all of their impacts on mothers, babies and midwives. Many midwives find themselves in a routine performance administering services to clients, most of whom they will not have met during the pregnancy and will not meet again after they have left the delivery room.

This is where our student midwives learn their craft; and sadly, most young midwives leaving college today have very limited experience with even witnessing a natural birth, let alone attending one.

Two of the German midwifery magazines carried articles on "violence in obstetrics" in their latest issues—they were not about some scandalous individual incident, but about normal hospital routine. Some accounts came from student midwives who were prepared to put a name to what they had seen (and been forced to take part in) and call it a violation of human rights. I hope that these young midwives, and indeed all of us, maintain empathy and treasure it—even if it gets in the way of job routine.

Change in Employment Status

Up until fairly recently, we had a system in Germany in which midwives either worked in hospitals where they were employees, or they worked as independent midwives—self-employed, in birth centres, sharing a practice, working on their own and/or attending women in their homes.

A hospital midwife thus would have her routine and her work shifts, but she would also have the security of a stable income, personal liability insurance covered by her employer and payment by her employer of a certain percentage of her social security contributions.

An independent midwife, on the other hand, is not bound by outside instructions and shift work (although her "shifts"—like attending a birth—might well be much more exhausting at times), but she works at her own economic risk. She has to find her own clients, do her own paper work, cover her social security contributions and pay for her own personal liability insurance (the cost of which has risen by about 400% over the last five years).

Now more and more German hospitals are threatening to close their delivery rooms and—instead of doing so—are transforming them into affiliated units and hiring their former employees to work there as self-employed midwives.

This trend started many years ago in smaller hospitals but is becoming more and more the norm. The reasons given are the obvious ones: a declining birth rate, less funding and cost reduction. While this solution is intriguing, it usually means that the now self-employed midwives are working under the same (and maybe more) pressure, but at their own economic risk.

Thus, we have a situation with a lot of so-called independent midwives and health insurers telling us "Look how much money we are spending on independent midwifery, and you can't possibly ask for more...!" but which in reality is just a shift of the birth-related costs away from the hospital budgets—without an actual change toward better and more individual care.

Negotiating a New Framework

I would like to look at the situation of the originally independent midwives, since these are the midwives my organisation the Bund freiberuflicher Hebammen Deutschlands (BfHD) primarily represent. (Having said that I need to point out that we are open to all types of independent midwives. We realize that the changes that are taking place are not what midwives may have wanted and we feel responsible to represent all midwives who work in self-employed situations.)

When I look at independent midwifery in its original meaning, I think of the work of a midwife as one who works with a continuity-of-care approach, who attends a woman right through pregnancy and birth (be it at home or in a birth centre), and who provides post-natal care.

I also think of the fact that all this work and all this responsibility is valued (in terms of financial earnings) less than that of a man who comes to repair a washing machine!

Our health care system is currently undergoing a major transformation called Gesundheitsreform—health care reform. This term sounds rather optimistic for what is happening. The era of a socialized economy is definitely over in this country. Like many of you know from your own countries, the health care sector is being transformed into free enterprise.

While saving money is the call of the day, money is not saved in the sector of state-of-the-art technology, but rather in human resources, mainly among those who have the least powerful lobbies behind them.

Our organisation, BfHD, is currently taking part in negotiations with the Board of Health Insurances for a new framework agreement that will lay out the future position of midwifery in Germany. Since negotiations are still ongoing, I am not able to say anything about their outcome. They are taking place in a fair and friendly atmosphere, but we do find it necessary at times to point out and prove to the health insurance representatives that we cannot fall below certain economic standards since we are expected to do extremely specialized work, dealing with life-and-death matters.

These are just a few facts about the situation of midwives here in Germany. I don't doubt that we are still far better off than many other countries, but don't doubt that we need many improvements—which leads back to the idea of visions and dreams.

Realize Your Dream

All of us—midwives, doulas, childbirth educators and administrators (like me)—have travelled here, some from very far, and have come for more than just a routine training course. We have come here because we know that this is a conference where we can gain—and share—knowledge about our craft and work on the visions we have about our daily work and the situation of pregnant and birthing women and their babies.
When you have a dream and want to put it into reality, you stop dreaming and start becoming active. You start by networking with people who have similar dreams. This is what we are doing here. Then you gather knowledge that will help you put your arguments on solid ground. That is also what we are doing here. We need to look at:

the inherent knowledge that we have and that we need to protect in our present-day circumstances, even when we are told from all sides that technology can do everything so much better;

the different birth cultures in different parts of the world. How do they do it? What is important for them/what can we incorporate into our own system?

the latest research. We have a lot of academic midwives, and other scientists, some of whom have given invaluable momentum to midwifery, doing research into all aspects of birth and maternity care. The beauty of this approach is that their findings support what midwives—and mothers—have known and done all along if allowed to.

Following our visions and dreams is really a very practical and down-to-earth thing. My wish for everyone at the conference is that we take home both the knowledge that we find here, as well as the spirit. Knowledge and spirit are the ingredients that make wisdom, and I am very grateful to Jan Tritten and to all the people at Midwifery Today for being so dedicated in spreading this wisdom.

Andrea Bolz is secretary of the Association of Independent Midwives of Germany (BfHD). She lives in Frankfurt, Germany, with her daughters Paula and Flora. She has a degree in English literature and worked as an arts administrator before becoming involved in women's health issues. BfHD supports independent midwives who work with a continuity-of-care approach and home birth midwives in particular.

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Through networking and education, Midwifery Today's mission is to return midwifery care to its rightful position in the family, to make midwifery care the norm throughout the world, and to redefine midwifery as a vital partnership with women.